ENT Follow-Up Visit Note:
Date and Purpose of Review:
1 November 2024, follow-up for chronic sinusitis and post-adenoidectomy assessment.
Subjective Update:
Patient reports significant improvement in nasal obstruction and facial pressure since initiating fluticasone spray. No new episodes of epistaxis. Occasional mild post-nasal drip, which is less bothersome than previously. Mother reports child is sleeping better and snoring has markedly reduced following adenoidectomy.
Objective Findings:
Otoscopy: Tympanic membranes intact, mobile, no effusion bilaterally.
Anterior Rhinoscopy: Mild mucosal erythema, no polyps visible. Septum midline.
Oropharynx: Clear, no tonsillar hypertrophy.
Neck: Supple, no palpable lymphadenopathy or masses.
Investigations or Procedures Reviewed:
Reviewed CT Sinus scan from 15 September 2024, which showed mild mucosal thickening in maxillary sinuses. Reviewed post-operative adenoidectomy report confirming complete removal. No new audiometry or lab results available for review.
Management Update:
Continue fluticasone nasal spray daily. Discussed proper technique for nasal spray administration. Advised on saline nasal rinses as needed for post-nasal drip. No changes to current medication regimen. Formulary availability for fluticasone confirmed through local pharmacy networks.
Plan:
Continue current management. Patient to return in 3 months for further follow-up to assess long-term response to medical management for sinusitis and ensure no recurrence post-adenoidectomy. No immediate referrals required.
ENT Follow-Up Visit Note:
Date and Purpose of Review:
[record visit date and reason for follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Subjective Update:
[document patient's symptom status, treatment response, and any new concerns since last visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Objective Findings:
[include exam findings relevant to ears, nose, throat, or neck based on follow-up focus] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Investigations or Procedures Reviewed:
[record interpretation of audiometry, imaging, endoscopy, or lab results, using standard public or private sector terminology and platforms in the South African setting] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Management Update:
[document medication changes, therapy adjustments, or surgical decision-making relevant to ENT follow-up. Reference formulary availability where relevant for South African context] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
Plan:
[outline ongoing management, referrals (e.g., to public ENT clinics, audiology, speech therapy), or discharge from ENT care] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)